Management of Hiv Care in Hard-to-reach Patient Populations*

People who inject drugs face stigmatization by society in general, and also by healthcare workers. This creates incentives for individuals with addiction to conceal their drug use, which can interfere with optimal medical care. There are several common misconceptions about individuals who use injection drugs, including the belief that they do not care about their health. The reality is that substance use is a complex disorder that includes biological, behavioral, and social aspects. Drug users are concerned about their health. There are several opportunities to connect patients with HIV infection and substance use problems to medical care, including community outreach programs, addiction treatment centers, and counseling-testingreferral sites. One of the most important points of contact with healthcare for many of these individuals is in the correctional system. In Rhode Island, where there is routine testing of almost all prisoners upon incarceration, approximately 33% of all people in the state with HIV have been identified during incarceration. Most states do not routinely test their incarcerated populations for HIV. Specialized programs to enhance HIV care in individuals who have recently been released from prison have been shown to retain a large proportion of patients in medical care for more than 1 year after prison discharge. Many clinicians assume that HIV-infected patients with addiction are poor candidates for antiretroviral therapy. These individuals are thought to be unlikely to adhere to treatment and to be at high risk for the development of drug-resistant HIV strains. However, there is evidence that there is little or no difference between injection drug users and nonusers in the development of drug-resistant HIV. A modified directly observed therapy approach, adapted from the directly observed therapy paradigm of tuberculosis treatment, may help to improve plasma viral load, CD4 cell counts, and other clinical outcomes in some difficult-to-reach patients with HIV infection and substance use disorders. (Adv Stud Med. 2006;6(3A):S123-S129)